Provider Demographics
NPI:1659907269
Name:SCHENK, KELLY (LCPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SCHENK
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10258 EXCHANGE RD
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286-3826
Mailing Address - Country:US
Mailing Address - Phone:618-443-7231
Mailing Address - Fax:
Practice Address - Street 1:325 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-1109
Practice Address - Country:US
Practice Address - Phone:618-443-7231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-14
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012813101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional